Hunger Quotes

“This “mind-mindedness” should be apparent in the way we think about and talk to the one we want to help and on how we think about and talk to each other. It is about curiosity and flexibility. It is about how we deal with crises and how we reflect about them. It is about supervision, exercises, role-play and video. It is about a minimum goal of common understanding, good management and a good working milieu.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Mentalization-based milieu therapy is not least a focus on management and the staff. The model provides practical help to support clinicians working with the most distressed patients and families in a way that helps them retain their own humanity, their own capacity to empathize and act sympathetically. We need structures to help the therapists to retain their ability to create a coherent image of the patient’s perspective. A main aim is to create a “mind-minded” mind.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Another reason could concern shame associated with eating disorder. Intense internal shame is an inner experience of the self as an unattractive social agent, under pressure to limit possible damage to the self via escape or appeasement (Gilbert 1998). Shame in this context could be described as the pain of not seeing oneself as being worthy of love. Shame represents a withdrawal (Skårderud 2007a, b). It might be difficult to contribute in the group because they might think “they are not worthy enough to say anything” and “what they have to say is not important for the group”. Another reason could be the groups’ teleological functioning in the form of patients comparing their own bodies with those of others in the group, and also with the therapists.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“It is tempting to state that sometimes the group therapy movement historically has presented a kind of omnipotence, seeing group encounters as a panacea for a vast array of suffering. A more in-depth understanding of eating disorders makes it probable that such approaches alone, with the emotional and relational complexity in intimate groups, for many patients will be inefficient or even counterproductive. This is particularly relevant in the early phases of treatment. The patients have described how encounters in the groups have triggered inferiority , shame and obsessive comparison . Perfectionist traits are common, leading to an over-concern with how they appear and perform in the group (Westen and Harnden-Fischer 2001). All these are emotional reactions that may lead to impaired mentalizing. This is illustrated through statements like “my thinking collapsed”, “I became blank”, “I sank into a deep hole of confusion”, “I am not worthy to contribute here” and “my preoccupation with the others’ negative views of me paralyzed me”.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“The aim of our treatment structure is to organize different therapeutic contexts in such ways that they separately, and, not least, together, enhance competences for reflexivity and self-regulation as well as symptom reduction. A rationale for a combination of different therapeutic contexts is that mentalizing is challenged in different ways and at different levels in the different contexts, as it is in everyday life, and the different settings provide diverse opportunities to practice .”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“The word respect comes from the Latin word respectus, which means the action of looking back. McWilliams (1999) emphasizes that the formulations encourage us to think about our patients as complex wholes, not just their weaknesses, but their strengths, not just their pathology but their health, not just their misperceptions but their surprising, unaccountable sanity under the worst of conditions.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“A ubiquitous problem faced by our patients is that they feel they are too heavy. This leads to attempts to diet which, associated with over-exercising, may lead to major weight loss and anorexia nervosa. Any degree of food restriction may trigger the body’s natural mechanisms, which counter the reduction in nutrition. These include thinking about food and feeling hungry, and the thoughts can become pervasive and last all day, sometimes even entering dreams. These responses are perfectly natural and act as important survival mechanisms which lead a hungry person to go in search of food. The more extreme the restriction, the more pronounced are the food preoccupations. If weight does go down, it is possible that the preoccupations and urges to eat may be even worse. Imagine someone in this state who eats a sweet treat. The food preoccupations become focused on the treat and expand into an insatiable urge to eat, which grows until satisfied. The degree of restriction and probably the degree of being underweight seem to determine the amount of food consumed and before long the patient is in the grip of an eating binge. Initially the satisfaction of the urge to eat can be pleasurable, but after a time, as more and more food is consumed, the patients become increasingly regretful and guilty, and these thoughts usually predominate in the aftermath. There then arises an urgent need to get rid of the food and reverse or at least mitigate the nutritional impact of the binge, and the patient may go to the toilet and put her fingers down her throat in order to induce vomiting. Huge relief accompanied by regret and guilt at the behaviour often accompanies this. The whole process of restriction, bingeing and vomiting with alternating need, satisfaction guilt and relief can become habitual and, some say, addictive.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“MBT-ED is an active approach. Therapy as a vitalizing activity, as an experience of aliveness, is a quality in its own terms beyond symptom reduction and enhanced self-understanding (Winnicot 1971; Ogden 1995; Skårderud and Fonagy 2012). For many patients, therapists who adopt more passive or reticent approach may prove threatening for different possible reasons. It may activate shame and negative self-evaluation, the patient being frightened of boring the therapist. It may nurture the fear of not performing well enough as a patient. It may activate feeling responsible for the well-being of the therapist, or it may stimulate the sense of deadness and “entombed” interaction we have described. All this is likely to impair the reflective function of the patient.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Psychic equivalence needs to be recognized and, as far as possible, challenged. There will be no progress while the patient is stuck in this way of experiencing reality. The therapist has one major task: get them out of it, if possible. It is fundamental to the symptoms of eating disorders, exemplified by the idea “I feel fat, therefore I am fat”.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“the term mentalizing—a verb. This is because mentalizing is an activity, a way of being, a general inquisitive stance rather than a set of specific techniques. Our aim is to explore this activity together with the patient.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“When the emotional climate in the therapeutic relationship is “too hot”, which can be due to aggression, fear or anxiety, the task of the therapist is to reduce intensity. The state of arousal inhibits mentalizing, and hence therapy cannot proceed satisfactorily. If it is “too cold”, in the meaning of detachment and polite talk, the mission is to make the encounter warmer and more engaged. Often when working with eating disorders, we experience the usefulness of activating affects, making cold warmer.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Mentalizing virtuously means being authentically interested and curious in exploring the richness of possible realities. Active questioning expresses curiosity, but should not be expected to yield an unequivocal answer, but progress towards a conceptualization of alternatives (Skårderud and Fonagy 2012”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Hence, Bruch, like Bateman and Fonagy, stressed the necessity of tailoring interventions to the patients’ way of psychological functioning (Skårderud and Fonagy 2012). In her posthumously published book Conversations with Anorexics (1988: 8), she writes: The therapeutic task is to help the anorexic patient in her search for autonomy and self-directed identity by evoking awareness of impulses, feelings, and needs that originate within herself. The therapeutic focus needs to be on her failure in self-experience, on her defective tools and concepts for organizing and expressing needs, and on her bewilderment when dealing with others. Therapy represents an attempt to repair the conceptual defects and distortions, the deep-seated sense of dissatisfaction and helplessness, and the conviction that her own self is empty and incomplete and that therefore she is condemned to compliance out of helplessness. Again, she called this a naïve stance.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“To Sum Up Mentalizing is both about self and others. One of the major impairments in severe eating disorders is minding oneself. Patients often refer to “inner chaos”, “unrest” and “being out of control”. The person with an eating disorder will have challenges in minding their own minds but also being sensitive to their own body signals. Hence, the concept embodied mentalizing. The mentalizing model is based in developmental psychology. A way of describing impaired mentalizing is via three forms of pre-mentalistic modes of experiencing psychic reality, psychic equivalence, teleological mode and pretend mode. None of these has the quality of a fully functional internal reality. Such theoretical constructs are highly relevant for eating disorders, and eating disorders are clinical cases that illustrate these constructs in highly concrete ways. The person who is most preoccupied with the external body may be the same person who has little contact with his or her own somatosensory signals, the lived body.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Brodie (1994) conclude that anorexia patients do not have a fixed and implacable distorted image of their own bodies. Rather, they have “uncertain, unstable and weak” body image (p. 41). If we see body image distortion as associated with the “mentalization of the body”, we would predict precisely such changes of bodily experience associated with changes in mental states. There are clinical indications consistent with this point of view. For example, fluctuation of body image appears to be associated with emotional states (Espeset et al. 2012). Anorectic patients may feel fatter when they feel frightened and anxious. As we know that negative affect tends to impair mentalizing in other patient groups, the association of body image distortion with negative affect could be a consequence of the intensification of mentalization failure as triggered by arousal, which then finds representation, not as a feeling of dis-ease but as an experience of physical discomfort and dissatisfaction with one’s body. The person who is most preoccupied with the external body may be the same person who has little contact with his/her own somatosensory signals, the lived body.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“(American Psychiatric Association 2013). In ICD-10 a diagnostic criterion is still: “There is body image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself” (World Health Organization 1993). Actually, this ICD-10 criterion does not accord with our experience. There are many anorexic persons without a distorted body image. In the latest version, ICD-11 (World Health Organization 2018) this possibility is recognized in the description of anorexia nervosa which includes the following: “Low body weight or shape is central to the person’s self-evaluation or is inaccurately perceived to be normal or even excessive.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Therapy” can go on for weeks, months, sometimes even years, in the pretend mode of psychic reality, where internal states are discussed at length, sometimes with excessive detail and complexity yet no progress is made, and no real understanding is experienced. Ideas do not form a satisfactory bridge between inner and outer reality, and affects do not accompany thoughts. Such phenomena are extremely well known from clinical work with eating disorders.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“The social difficulties experienced by patients with anorexia are not only caused by the patients’ deficits in interpreting others’ minds. There is evidence that they present an unemotional “flat” face to others (Lang et al. 2016), and this can lead to failed social encounters. This is reminiscent of babies’ extreme distress when their mothers presented an unmoving expression to them, just for a minute or two (Weinberg et al. 2008; Tronick 2018). In other words, we are all expecting emotional expression in others and find it very unpleasant when we meet someone who presents a flat, unemotional face. The dependency on confirmation from others corresponds with major trends in contemporary culture, with great emphasis on visuality, bodily surfaces, external qualities, performances, etc. A central psychological trait in both contemporary culture and highly aggravated in eating disorders is the emphasis on comparison and comparison anxiety . Many are obsessively comparing themselves with others, concerning bodies, numbers and amounts of food, hence depending on profoundly superficial data.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Such disconnections between physiological, subjective feeling components of emotion and language have long been talked of as alexithymia. This is defined as greatly reduced or absent symbolic thinking, outbursts of affect without being able to explain or connect them to relevant feelings and inhibited fantasy (Sifneos et al. 1977). Alexithymia includes difficulty identifying feelings, describing feelings to other people, a manifest paucity of fantasies and a stimulus-bound, externally orientated cognitive style. The incidence of alexithymia has been estimated at 66–75% in eating disorder populations across several studies versus 6–26% in non-patient controls (Bourke et al. 1992; Cochrane et al. 1993; Deborde et al. 2008; Schmidt et al. 1993). Alexithymia is in our conceptual model an aspect of and an index of disrupted mentalizing.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Hilde Bruch (1904–1984) is probably the most influential and important figure in the field of eating disorders (Skårderud 2013). Immensely productive, she was a prolific author, both for scientific and popular audiences (Lidz 1994; Bruch 1996). She wrote extensively on various topics in psychiatry and psychotherapy, on obesity and eating disorders in general, but is probably best known for her work on anorexia nervosa. She developed new vistas in the understanding and conceptualization of this particular psychopathology. Hilde Bruch was also a pioneer in developing the psychotherapeutic approach towards such disorders, with emphasis on curiosity and a not-knowing stance (Bruch 1970). Her ways of proposing psychotherapeutic enterprises and stances for eating disorders are highly coincident with a mentalizing stance. Her concepts of “naïve stance” and “constructive use of ignorance” are synonymous to the not-knowing position so central in mentalization-based treatments. And,”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“In general, the prevalence of secure attachment is low across all diagnostic subgroups of eating disorders. In addition to individuals with such acquired deficits in affect regulation, however, there are individuals with inherited deficits in their neurobiological functions that may predispose them to affective dysregulation (Barry et al. 2008; Belsky 2006). We can conceive of persons with eating disorders as attempting to drown out anguished feelings by frantic self-stimulatory activities. This could be seen as a common denominator to such behaviours as starvation, bingeing, vomiting and hyperactivity. The absence of reliable internal self-regulation may cause the eating disordered patient to feel inadequate, ineffective and out of control. The symptoms can be seen as misguided attempts to organize emotions and other internal states more meaningfully.”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders

“Good mentalizing refers to mental and relational strengths as curiosity, perspective taking, forgiveness, reflective contemplation, a trusting attitude, humility, playfulness , willingness to assume responsibility and accept accountability and being aware of one’s impact on others (Bateman and Fonagy 2016”
― Paul Robinson, Hunger: Mentalization-based Treatments for Eating Disorders